Fundamentals Exam #3

The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies? 1. Increase of blood flow to the uterine muscle 2. Avoidance of uterine contraction 3. Minimization of menstrual flow 4. Decrease in estrogen production

1. Increase of blood flow to the uterine muscle

When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes? Select all that apply. 1. The respiratory rate can increase up to 40 breaths per minute. 2. Involuntary muscle spasms occur throughout the body. 3. The heart rate decreases to 20 beats below normal. 4. Systolic blood pressure can increase 20-30 mm Hg above normal. 5. Diastolic blood pressure can decrease 20-50 mm Hg below normal.

1, 2, 4

The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a health care provider? Select all that apply. 1. Puckering of the skin 2. Flattening of the breast from the side view 3. Free movement of the breast over the chest wall 4. Symmetry of the nipples 5. Change in shape

1, 2, 5

After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms. According to Freud, what should the nurse realize as being the cause of this behavior? Select all that apply. 1. Anxiety created by conflicts 2. Activation of the conscience 3. Conflict between the id's impulses 4. Immediate pleasure and gratification 5. Underlying motivation for development

1, 3

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern? Select all that apply. 1. "I hate my hair." 2. "Life is wonderful!" 3. "My hips are too big." 4. "I wish I had that nose job 2 years ago." 5. "It is awesome that I got that promotion at work."

1, 3, 4

The nurse is assessing a child's growth and development. What questions should the nurse ask the parents that demonstrate an understanding of the factors that affect growth and development processes? Select all that apply. 1. How tall the parents are 2. Whether noises seem to bother their child 3. How many ounces of formula their child drinks daily 4. What their yearly income is 5. Whether their child will receive day-care services

1, 2, 3

The nurse is preparing to assess a client's sexual health. What will the nurse include in this assessment? Select all that apply. 1. Sexual self-concept 2. Body image 3. Gender identity 4. Contraceptive choices 5. Employment

1, 2, 3

An adult client who has been a successful writer in the past has been experiencing low self-esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes? Select all that apply. 1. The client joined a library book club. 2. The client counted the number of rejection letters she received from publishers. 3. The client states that she no longer reads Facebook to compare her life with her friends' lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition.

1, 3, 4, 5

After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client? Select all that apply. 1. Knowledge about sexual behavior 2. Reluctance to discuss sexual history 3. Utilization of birth control method that fits lifestyle 4. Statement that there are no issues with sexuality 5. Discussing sexual problems with healthcare provider

1, 3, 5

The nurse is discussing human growth and development with the parents of a newborn. What should the nurse include in this discussion? Select all that apply. 1. Growth involves physical change and increase in size. 2. Skills and function increase with growth. 3. Most humans experience a similar pattern of growth. 4. Being able to adapt to one's environment is an indicator of growth. 5. Children's growth is monitored by height, weight, bone size, and dentition.

1, 3, 5

The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse instruct these participants to follow? Select all that apply. 1. Monthly breast self-exams for women 2. Yearly breast self-exams for men 3. Weekly testicular self-exams for men 4. Monthly breast self-exams for men 5. Yearly vulvar self-exams for women

1, 4

Which statement should the nurse make first when assessing a client's self-concept? 1. "Describe yourself as a person." 2. "Tell me about your family." 3. "Describe what you do when you have free time." 4. "Tell me about the work you do."

1. "Describe yourself as a person."

Which statement made by a new mother would indicate to the nurse that there is potential for lowered self-esteem due to role ambiguity? 1. "I don't know if I know how to be a mom." 2. "My husband will be a stay-at-home dad while I work." 3. "I'm so disappointed that this baby is not a girl." 4. "I haven't even finished the baby's room."

1. "I don't know if I know how to be a mom."

A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter on a daily basis. Remembering the growth and development characteristics of the adolescent, how should the nurse respond to this client? 1. "You should feel very proud for understanding and using your meter." 2. "Think of using the meter as one of your daily chores." 3. "Maybe you could make a game out of the daily use of your meter." 4. "It's too bad if you don't want to use the meter, it's just something you'll have to do."

1. "You should feel very proud for understanding and using your meter."

The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon which concept? 1. Alcohol is a central nervous system depressant that affects judgment. 2. Erectile dysfunction only occurs after years of alcohol abuse. 3. Alcohol is a sexual stimulant. 4. Erectile dysfunction occurs only in men older than 50.

1. Alcohol is a central nervous system depressant that affects judgment.

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self-esteem. What intervention would be appropriate for this resident? 1. Ask the resident for advice in setting up an activity in the dayroom. 2. Keep the resident too busy to dwell in the past. 3. Don't allow the resident to talk about minor concerns. 4. Meet with the social worker to plan all of the client's care.

1. Ask the resident for advice in setting up an activity in the dayroom.

The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern? 1. At 20 months this touching is not a sexual experience. 2. Masturbation to orgasm is common and normal at this age. 3. Genital stimulation should not be occurring until the age of 2 1/2 or 3. 4. Babies are sexual beings, but this activity should be discouraged.

1. At 20 months this touching is not a sexual experience.

A nurse colleague learns that a grandchild's day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept? 1. At this age, education regarding sexuality should come from parents. 2. Children are sexual beings from before birth. 3. Understanding the body and sexuality are a part of growth and development. 4. Sexual activity is beginning at earlier and earlier ages.

1. At this age, education regarding sexuality should come from parents.

The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ? 1. Encourage the client to set attainable goals, even if small. 2. Help the client choose a significant goal, even if it is time consuming. 3. Devise a set of goals from which the client can pick. 4. Advise the client to avoid goals that will require too much effort.

1. Encourage the client to set attainable goals, even if small.

During a sexual assessment, a client tells the nurse about a preference for oral-genital sex. How should the nurse instruct this client? 1. Explain the need to follow safe sex practices. 2. Explain the need to use contraception. 3. Explain the importance of having an annual HIV test. 4. Explain thy routine gynecologic examinations are not necessary.

1. Explain the need to follow safe sex practices.

The nurse and client had set the following expected outcome: "At the next clinic visit, the client will report participation in three activities to increase self-esteem." At today's visit, the client is unable to meet the stated outcome. What should be the nurse's next action? 1. Explore the possible reasons for not meeting the outcome. 2. Reevaluate the accuracy of the outcome statement. 3. Collaborate with the client to write a new expected outcome. 4. Identify new interventions to help the client achieve the outcome.

1. Explore the possible reasons for not meeting the outcome.

The nurse is preparing educational materials to be used when instructing clients on testicular and breast self-examination. What would be applicable for both sets of instructions? 1. Perform palpation in the shower. 2. Perform the examination lying down. 3. Perform the examination once each week. 4. Perform the examination bimonthly.

1. Perform palpation in the shower.

The nurse is caring for a very ill, single mother of two, with cancer who is undergoing chemotherapy. The mother is experiencing significant stress because she is the sole provider for her family. Which of the following describes the clients role problem? 1. Role Conflict 2. Role Strain 3. Role Ambiguity 4. Role Overload 5. Sick Role

1. Role Conflict

A nursing student has just received an evaluation that indicates difficulties with time management and prioritization in the care of clients. How should the student react to this input? 1. Take the feedback seriously and use it to guide personal growth. 2. Blame the student-faculty relationship as the basis of the evaluation. 3. Dismiss the evaluation as invalid. 4. Consider the feedback carefully but not change practice patterns.

1. Take the feedback seriously and use it to guide personal growth.

A child is starting school and is being screened for certain developmental milestones. What is the nurse assessing when determining how the child interacts with other children? 1. Temperament 2. Physical characteristics 3. Environment 4. Culture

1. Temperament

A parent brings her baby in for a well-child checkup. Which action of the child should the nurse identify as an indicator of positive resolution of the central task of this age? 1. The child does not cry when the parent allows the nurse to hold the child. 2. The child shows mistrust when strangers approach. 3. The child becomes willful when disciplined. 4. The child does not play with other children.

1. The child does not cry when the parent allows the nurse to hold the child.

A rare malignancy will require the amputation of an adolescent client's leg. The client refuses the surgery, stating: "I would rather die than have my leg amputated." What information should the nurse use to plan future interventions for this client? 1. The knowledge that adolescents are very concerned about body image 2. Concern about need for education regarding the danger of delaying surgery 3. The fact that the parents will have the ultimate decision about surgery 4. The ability of the adolescent to understand medical terminology

1. The knowledge that adolescents are very concerned about body image

A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous? 1. They do not limit behaviors to one gender over the other. 2. They are attracted to people of the same gender. 3. They often repress their sexual feelings. 4. They hold rigid stereotyped gender role expectations.

1. They do not limit behaviors to one gender over the other.

During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the client's 1. personal identity. 2. body image. 3. role performance. 4. self-esteem.

1. personal identity.

The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history? Select all that apply. 1. "What are your erotic fantasies?" 2. "Are you currently sexually active?" 3. "Do you experience any pain with sexual interaction?" 4. "Do you have difficulty with sexual desire?" 5. "What do you like the best about having sex?"

2, 3, 4

While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurse's breast. What should the nurse do about this behavior? Select all that apply. 1. Ignore the fondling. 2. Move the client's hand away. 3. Refocus the client on appropriate behavior. 4. Tell the client to stop performing the behavior. 5. Communicate that the behavior is not acceptable.

2, 3, 4, 5

The nurse is planning to assess a client's family relationships. What questions should the nurse ask to obtain this information? Select all that apply. 1. "How do you spend your free time?" 2. "What is your home like?" 3. "Who is most important to you?" 4. "How well do you feel you accomplish what is expected of you?" 5. "Whom do you seek out for help?"

2, 4

The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse? 1. "Most clients make quicker progress." 2. "Self-esteem work takes time and is not easily evaluated." 3. "What have you done to help the client with this work?" 4. "Do you think that the client is really trying?"

2. "Self-esteem work takes time and is not easily evaluated."

The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears mismatched clothing. What should be the nurse's response to this concern? 1. "Don't worry, day-care workers are accustomed to that sort of thing." 2. "This is normal and the preschooler is just practicing skills needed later in life" 3. "I am glad you brought that to our attention. I will make a note for her pediatrician." 4. "You should have better control of the child now if you have any hope of controlling the child during the teenage years."

2. "This is normal and the preschooler is just practicing skills needed later in life"

Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client? 1. Low motivation to improve 2. A focus on problems 3. Expressed disinterest in working on improvement 4. Not satisfied with personal situation

2. A focus on problems

A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best? 1. A woman with 35 years of teaching experience 2. A man who is 40 years old 3. A newly graduated 22-year-old man 4. A 30-year-old woman

2. A man who is 40 years old

A nurse is working with the residents of an assisted living complex. When planning care for the old-old stage, the nurse realizes that what action will be important? 1. Provide as much care to the residents as possible. 2. Allow as much independence for the residents as possible. 3. Make sure to provide safety measures as needed. 4. Make sure the residents maintain peer interactions and social groups.

2. Allow as much independence for the residents as possible.

During a routine physical, an 11-year-old tells the nurse that many students in school are "doing it." How should the nurse respond to this statement? 1. Tell the client to talk with parents about sexual matters. 2. Ask what "doing it" means to this client. 3. State that sexual activity is not appropriate at age 11. 4. Stay silent and wait for the client to continue the discussion.

2. Ask what "doing it" means to this client.

The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is "always exposing and playing with himself and his catheter" while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurse's priority action? 1. Tell the client to keep his hands away from his penis. 2. Assess the client's penis for irritation from the catheter. 3. Ask the client to keep his linens at waist level when he has visitors. 4. Collaborate with the physician regarding medications to control this behavior.

2. Assess the client's penis for irritation from the catheter.

During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the client's reluctance to share information? 1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt.

2. Consider any cultural implications of these actions.

Which nursing intervention would be helpful when caring for a client who has negative self-esteem? 1. Find a way to praise the client during each encounter. 2. Design a series of "small successes" for the client. 3. Correct the client when negativity arises. 4. Tell the client how much easier life would be with positive self-esteem.

2. Design a series of "small successes" for the client.

A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment, the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a sitting position. In which process should the nurse identify that this child is lagging? 1. Growth 2. Development 3. Height 4. Behavior

2. Development

A client who has a terminal diagnosis has been using her time to help family members deal with her impending death. Among her activities, she collected pictures for a scrapbook and wrote a journal of favorite memories for family members to read after the client dies. According to Peck, the nurse realizes that this client is working through which developmental task? 1. Body transcendence versus body preoccupation 2. Ego transcendence versus ego preoccupation 3. Ego differentiation versus work-role preoccupation 4. Integrity versus despair

2. Ego transcendence versus ego preoccupation

The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary? 1. Referral to a surgeon for excision of infected tissue 2. Examination and treatment of sexual partner 3. Treatment with a stronger oral antibiotic 4. Routine douches with a topical antibiotic solution

2. Examination and treatment of sexual partner

A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. The nurse identifies which nursing diagnosis as appropriate for the client at this time? 1. Chronic Low Self-Esteem 2. Ineffective Role Performance 3. Disturbed Body Image 4. Parental Role Conflict

2. Ineffective Role Performance

A parent reports to the nurse that his child is learning new words faster than he can write them in the baby book. According to Piaget, the nurse realizes that this child is in which phase? 1. Intuitive thought phase 2. Preconceptual phase 3. Concrete operations phase 4. Formal operations phase

2. Preconceptual phase

The nurse enters the room and finds the adult client masturbating. What action should the nurse take? 1. Tell the client that masturbation is harmful to sexual well-being. 2. Say "excuse me" and leave the room. 3. Request that the client stop so that care can be provided. 4. Ask the client if there are any sexual concerns that should be discussed.

2. Say "excuse me" and leave the room.

The nurse notes that a 20-month-old child is lagging in stage 6 of Piaget's phases of cognitive development. Which activity did the nurse observe that indicates that this child is struggling at this stage? 1. The child wants the same toy to sleep with during naptime and bedtime. 2. The child merely watches as the other children pretend-play. 3. The child cries when the parents leave the unit. 4. The child does not cooperate with some of the treatments.

2. The child merely watches as the other children pretend-play.

In discussion with teenagers, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice? 1. Infection is a much more precise term for the transmission that occurs. 2. The word disease may elicit guilt, shame, and fear in the client. 3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection. 4. These terms can be used interchangeably and there is no good rationale for using one over the other.

2. The word disease may elicit guilt, shame, and fear in the client.

The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only? 1. Genitalia and breasts return to pre-excitement states. 2. There is a refractory period during which the body will not respond to sexual stimulation. 3. The heart rate returns to normal. 4. Possible sleepiness or intense relaxation may occur.

2. There is a refractory period during which the body will not respond to sexual stimulation.

A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates 1. role confusion. 2. body image disturbance. 3. fear of success. 4. lack of education.

2. body image disturbance.

The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior 1. may indicate sexual abuse by the father and should be further investigated. 2. is a normal expectation of a preschooler developing sexuality. 3. indicates that the girl is overidentifying with the male gender. 4. can be a sign of precocious puberty and should be monitored.

2. is a normal expectation of a preschooler developing sexuality.

After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the client's list caused the nurse to make this clinical decision? Select all that apply. 1. Antibiotics 2. Antipyretics 3. Cardiotonics 4. Beta-blockers 5. Anticoagulants

3, 4

The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase? Select all that apply. 1. The vagina dries. 2. The length of the vagina narrows and swells. 3. Erection of the clitoris occurs. 4. The breasts enlarge. 5. The uterus elevates.

3, 4, 5

Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment? 1. "For some reason, I have more sexual desire than ever." 2. "I use water-soluble lubricant to treat my vaginal dryness." 3. "I am so glad that I don't need to worry about sex anymore." 4. "Sex certainly takes longer than it used to, but I'm getting used to that."

3. "I am so glad that I don't need to worry about sex anymore."

Which statement, made by the client, would indicate a "me-centered" self-concept? 1. "I couldn't stand to disappoint my parents." 2. "My sister is so much smarter than I am." 3. "My future is based on the decisions I make today." 4. "The world has always been against people like me."

3. "My future is based on the decisions I make today."

A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurse's best response to this client's concerns? 1. Sexually transmitted infections may result in sexual problems in adults. 2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection. 3. An occasional incident like this is normal and common and there is no reason to be concerned. 4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.

3. An occasional incident like this is normal and common and there is no reason to be concerned.

A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult? 1. Early menopause 2. Increased menstrual flow 3. Chronic urinary tract infection 4. Tendency for postpartum hemorrhage

3. Chronic urinary tract infection

The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client? 1. Even though she doesn't get pregnant, she might still get a sexually transmitted infection. 2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm. 3. Conceiving is not related to whether or not the female partner experiences an orgasm. 4. As long as her boyfriend does not ejaculate in her vagina, conception is unlikely.

3. Conceiving is not related to whether or not the female partner experiences an orgasm.

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freud's theory of development, the nurse should suspect that this person would be fixated at which stage of development? 1. Phallic 2. Latency 3. Genital 4. Anal

3. Genital

A client recovering from a lumpectomy for breast cancer tells the nurse that she "feels ugly." For which nursing diagnosis should the nurse plan interventions? 1. Powerlessness 2. Social Isolation 3. Grieving 4. Hopelessness

3. Grieving

The nurse is plotting the height and weight of children during a school assessment clinic. Which aspect of the children's health is the nurse assessing? 1. Development 2. Health 3. Growth 4. Bone size

3. Growth

The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data? 1. This couple is experiencing sexual dysfunction. 2. The woman's lack of sexual desire has resulted in impotence in her husband. 3. If both partners share the same lack of desire, there is often not a problem. 4. This situation is so unnatural that some dysfunction is present.

3. If both partners share the same lack of desire, there is often not a problem.

The nurse is exploring the behavior of children and how they interpret right from wrong or bad from good. Which theorist should the nurse study to learn this information? 1. Vygotsky 2. Skinner 3. Kohlberg 4. Piaget

3. Kohlberg

A toddler shows fear and begins to cry when her parent leaves her at day care. According to Havighurst, which developmental task should the nurse recognize this child is exhibiting? 1. Building wholesome attitudes toward oneself 2. Learning to get along with age-mates 3. Learning to relate emotionally 4. Achieving personal independence

3. Learning to relate emotionally

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses' self-concept along with information to use with clients. Why is the information for nurses important? 1. The nurse's self-concept is more important than the client's. 2. Poor self-concept is the number-one reason for nursing burnout. 3. Nurses with positive self-concept are better able to help clients. 4. Nurses with poor self-concept are more likely to make errors.

3. Nurses with positive self-concept are better able to help clients.

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included? 1. If the baby awakens at night, let him cry for a few minutes before responding. 2. Keep the baby on a 3-hour feeding schedule, even if it means awakening him. 3. Respond to the baby's needs promptly and consistently. 4. Use firm, loving discipline with the baby from the beginning.

3. Respond to the baby's needs promptly and consistently.

The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination? 1. Culture tubes to assess expected vaginal infection 2. Extra cleaning supplies to remove thick external secretions 3. Smaller-than-normal vaginal speculums 4. Equipment for preexamination douche

3. Smaller-than-normal vaginal speculums

The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include? 1. Tampons should not be used until the menstrual cycle is well established, usually 2 to 3 years after the first period occurs. 2. Superabsorbent tampons should be used at night to protect from overflow accidents. 3. Tampons should be alternated with sanitary pads to help decrease risk for infection. 4. Tampons should be changed at least every 8 hours.

3. Tampons should be alternated with sanitary pads to help decrease risk for infection.

A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response? 1. As long as intercourse is not involved, there is no reason to avoid sexual activity. 2. Some residual physical weakness is common for up to 18 hours after sex. 3. This is a common myth among athletes, but there is no basis in fact. 4. In fact, sexual activity before intense physical exercise increases stamina and endurance.

3. This is a common myth among athletes, but there is no basis in fact.

A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: "I am so worried about him and I know he is going to hell." What is the most important fact for the nurse to consider in formulating a response to this client's concern? 1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved. 2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern. 3. What constitutes normal sexual expression varies among cultures and religions. 4. Sexual development is genetically determined and not affected by environment.

3. What constitutes normal sexual expression varies among cultures and religions.

The adolescent male client who weighs 100 is considering taking "some herbal stuff" to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has 1. a strong need for admiration. 2. serious problems with logical thinking. 3. incongruence between reality and ideal self. 4. the need for referral to a psychologist.

3. incongruence between reality and ideal self.

The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask? 1. "Do you have any difficulty with sexual desire and orgasm?" 2. "How often do you have sexual relations?" 3. "What type of contraception do you use?" 4. "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?"

4. "Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?"

The parents of an adolescent report that their child has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. They ask for the nurse's professional opinion about the suitability of the punishment. Which answer best supports self-esteem development in this adolescent? 1. "I think the punishment may be excessive. Have you talked with the school officials about the incident?" 2. "Because my expertise is in health, I really can't respond to your question." 3. "Honesty and respect for authorities is important. I am surprised that the punishment is not more extensive." 4. "Living with the consequences of your actions is a way to help the adolescent develop good self-esteem."

4. "Living with the consequences of your actions is a way to help the adolescent develop good self-esteem."

A parent is concerned that her 5-year-old is beginning to masturbate. How should the nurse, familiar with Freud's stages of development, respond? 1. "All children are curious, but make sure the child knows that this behavior might be offensive to others." 2. "You should probably consult a child psychologist if you're this concerned." 3. "Let's make sure to ask your physician at the next appointment." 4. "This behavior is a normal part of your child's development."

4. "This behavior is a normal part of your child's development."

The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, "I learn something new about nursing every day." What does this indicate about the mentor's self-awareness? 1. This nurse is not very self-aware. 2. The mentor's self-awareness is behind normal development. 3. Because this mentor has been a nurse for so long, self-awareness is no longer an important issue. 4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior.

During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity? 1. Intersex 2. Transgenderism 3. Homosexuality 4. Cross-dressing

4. Cross-dressing

A community health nurse is planning adult health education classes. According to Erikson's stages of development, the nurse should address which task with this age group? 1. Industry versus inferiority 2. Identity versus role confusion 3. Intimacy versus isolation 4. Generativity versus stagnation

4. Generativity versus stagnation

A client is being seen in the mental health clinic for antisocial behavior. According to Erikson's stages of development, the nurse realizesthat this client is dealing with which task of development? 1. Initiative versus guilt 2. Industry versus inferiority 3. Intimacy versus isolation 4. Identity versus role confusion

4. Identity versus role confusion

The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment? 1. Take detailed notes to record client responses. 2. Ask as many questions as possible to explore all areas of concern. 3. Start the interview by asking a series of yes/no questions. 4. Investigate the client's culture prior to the interview.

4. Investigate the client's culture prior to the interview.

There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable? 1. A complete sexual history must be included in the admission history and physicals. 2. Sexual information should be pursued only if the client's chief complaint indicates possible sexual dysfunction. 3. Sexual assessment should be done by the physician and not repeated by the nurse. 4. The amount of sexual information taken will vary on a case-by-case basis.

4. The amount of sexual information taken will vary on a case-by-case basis.

The nurse is about to take a patient from the holding area to the surgical suite for a colonoscopy. Upon taking the patient's vital signs, the nurse notes a mild elevation in heart rate and blood pressure from the last assessment. Which component of the general adaptation syndrome is occurring? 1. Exhaustion phase 2. Panic phase 3. Resistance stage 4. Recovery stage 5. Alarm Reaction Phase 6. Adherence stage

5. Alarm Reaction Phase

The Tanaka family is experiencing stress related to the hospitalization of the father, age 50, for a severe MI. There are three children aged 19, 15, and 12. Mrs. Tanaka passed away one year ago. Which of the following nursing interventions would be appropriate in the plan of care? Select all that apply. A. Prepare Mr. Smith for anticipated situational crisis B. Counsel the family on temporary role changes needed C. Refer the family to community services D. Call child protective E. Ask for a social work consult F. Assess the client for adaptation to temporary role change

A, B, C, E, F

Which of the following complementary interventions may a nurse use without specialized licensing or certification? Select all that apply. A. Guided imagery B. Therapeutic touch C. Meditation D. Music therapy E. Massage therapy

A, C, D Explanations: B-not licensed but you do get certified

The nurse is teaching parents about normal sexual development. Which statements by parents warrant further teaching? (Select all that apply) A. "When my 2 year old touches his genitals I push his hand away and tell him No." B. "When asked questions about sexual development, I should answer my my 10 yr old in a developmentally appropriate, factual manner." C. "I should teach my 13 year old about contraception and sexually transmitted diseases at a developmentally appropriate level." when appropriate D. "I should allow my teenager to establish her own beliefs and moral value system by not sharing my own beliefs with her."

A, D

The nurse is assessing patients for self-concept in the outpatient setting. Which patient is least likely to develop problems related to self-concept? A. 60 year old TV reporter undergoing hysterectomy B. 32 year old clergyman whose vocal cords are paralyzed after a motorcycle accident C. 30 year old who survives a massive heart attack while hiking D. 23 year old model who just learned she has breast cancer

A. 60 year old TV reporter undergoing hysterectomy

A patient with terminal cancer tells the nurse "I'm no longer afraid to die-I'm at peace with it." This reflects what stage of death and dying? A. Acceptance B. Anger C. Bargaining D. Denial E. Coping

A. Acceptance

Susan is a 20 year old college student with self-esteem issues. She is 5'2" and weighs 100 pounds and states she is fat. Which of the following represents this perception? A. Altered body image B. Altered personal identity C. Altered self-concept D. Altered role conflict

A. Altered body image

A patient with terminal liver cancer tells his wife that he wants no more aggressive treatment to prolong his life such as chemotherapy. Which type of order would be appropriate? A. Comfort measures only B. Do not hospitalize C. Slow code only D. Do not resuscitate

A. Comfort measures only Explanations: C. Slow code only - completely illegal. Nurse thinks patient is in DNR

A nurse is admitting a patient for colonoscopy. The clients vital signs are: Pulse 102, Respirations 28, BP 152/88. The patient tells the nurse "I am really stressed about all this. It is my first time in a hospital." Which of the following complementary interventions might the nurse suggest in this situation? A. Provide more explanation and offer a relaxation technique B. Call the provider and request a dose of valium C. Bring the patient a tablet and suggest he draw to relax D. Give the patient a therapeutic back massage and tell him to relax

A. Provide more explanation and offer a relaxation technique

A hospice nurse is caring for an adolescent with a terminal illness on a ventilator at home. The patient asks the nurse to "please help me end it all." Which response from the nurse reflects the current nursing position on assisted suicide? A. The nurse explains that she will do everything possible to provide comfort but she cannot assist in ending the patient's life B. The nurse tells the patient that under no circumstances can the ventilator be removed C. The nurse agrees with the patient and removes the ventilator D. The nurse tells the patient that she is against assisted suicide but will find someone that will help him

A. The nurse explains that she will do everything possible to provide comfort but she cannot assist in ending the patient's life

The nurse is caring for a patient who is dying of liver cancer. The patient tells the nurse he has "lost all connection with God." What is the nurse's best response to the patient? Select all that apply A. Give the patient a hug and tell him "the connection is still there, he just lost it for a moment." B. "It's important to talk about your feelings but I'm not the best person for this issue, May I arrange for a spiritual advisor to visit you?" C. Ask the patient if he would like to talk more about his feelings D. Have a friend visit the patient E. Tell the patient "religion is over rated. No need to worry"

B, C, D

Which of the following are ways in which the nurse can support a grieving family? Select all that apply. A. Leave the family alone; enter only when necessary B. Explain the changes that may occur as the patient approaches death C. Encourage the family to stay with the deceased as needed D. Support parents to hold their deceased newborn if desired E. Spend time with the family telling jokes or otherwise lightening the mood F. Provide a space for the family away from the patient's room to process grief

B, C, D, F

Ms. K a single mother of two children, just lost her job and is worried about how she will feed her family. She presents with unbearable headaches. Which physiologic effects of stress would be expected findings in this patient? Select all that apply A. Angry outbursts at work B. Change in appetite C. Change in pulse and respirations D. Withdrawal from friends and family E. Change in elimination patterns

B, C, E

Ms. D requires care by only female providers. Based on known religious preferences, what is Ms. D's religion? A. Roman Catholic B. Islam C. Buddhist D. Jehovah's witness E. Orthodox Jew

B. Islam

The nurse is counseling a 65 year old couple regarding sexuality. Which statement from the couple should the nurse address? A. "We need more time for sexual stimulation than we used to." B. "We have less sex but we are still intimate." C. "We're at an age when we should consider ceasing sexual activity." D. "We still have sex but have to change positions to be comfortable."

C. "We're at an age when we should consider ceasing sexual activity."

The nurse is performing spirituality assessments of patients in a long term care home. What is the best question the nurse might ask to determine how the staff can be supportive? A. "Please describe your usual spiritual practices and how you maintain them." B. "Are your spiritual beliefs causing you any concerns today?" C. "What can the nursing staff do to help you maintain your spiritual practices?" D. "Do your religious beliefs help you feel at peace?"

C. "What can the nursing staff do to help you maintain your spiritual practices?"

Mr. Miller, 70, is 5 days post MI and cardiac catheterization. He expresses concern that his "sex life is over now." The best response from the nurse is: A. "Sounds like something you better discuss with Mrs. Miller when you get home." B. "No worries, everything down there will be working just fine." C. "You are still having sex, really?" D. "Sounds like you are concerned. Let's discuss the realities of sex after a heart attack."

D. "Sounds like you are concerned. Let's discuss the realities of sex after a heart attack."

The nurse is assessing her patient who is 8 months pregnant. The patient states "I'm really worried about being able to handle the pressure of parenthood." Which diagnosis would be most appropriate for this patient? A. Situational low self-related to fear of parenting B. Ineffective denial related to ability to care for a newborn C. Ineffective coping related to the new parenting role D. Anxiety related to change in role status E. Role conflict related to change in relationship with husband

D. Anxiety related to change in role status

An ER nurse is assessing how the spiritual beliefs of her patient may affect the treatment plan. Which patient is most likely to resist emergency lifesaving surgery? A. Roman Catholic B. Seventh Day Adventist C. Buddhist D. Jehovah's witness E. Orthodox Jew

D. Jehovah's witness ~ no blood products